How would you monitor this patient during the perioperative period?
Electrocardiographic monitoring is essential in the management of patients with dilated cardiomyopathies, particularly in those with myocarditis. Ventricular dys-rhythmias are common, and the development of complete heart block requires rapid diagnosis and treatment. The electrocardiogram (ECG) is also useful for monitoring of ischemic changes when CAD is associated with the car-diomyopathy, as in amyloidosis. Direct intra-arterial blood pressure monitoring during surgery provides continuous blood pressure information and a convenient route for obtaining arterial blood gases.
Any patient in CHF with a severely compromised myocardium who requires anesthesia and surgery should have central venous access for monitoring and vasoactive drug administration. The use of a pulmonary artery catheter is much more controversial, but is probably of value in patients with severely compromised left ventricular function. While there is no evidenced-based medicine to support outcome differences, left-sided filling pressures should be monitored, if at all possible. Monitoring right-sided filling pressures is of equal importance in patients with pulmonary hypertension or cor pulmonale. In addition to measuring filling pressures, a thermodilution pulmonary artery catheter can be used to obtain cardiac outputs and the calculation of systemic and pulmonary vascular resistances, which allow for serial evaluation of the patient’s hemodynamic status. Additionally, there are pulmonary artery catheters with fiberoptic oximetry, and rapid-response thermistor catheters that calculate right ventricular ejection fraction. Pacing catheters and external pacemakers provide distinct advantages in man-aging the patient with myocarditis and associated heart block.
Two-dimensional transesophageal echocardiography pro-vides useful data on the response of the impaired ventricle to anesthetic and surgical manipulations. The short-axis view of the left ventricle would provide real-time information on preload and ventricular performance that would be valuable in judging the need for inotropic support or vasodilator therapy. The degree of mitral regurgitation could also be followed intraoperatively.